thesis about funeral service

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Cremation and Grief: Are Ways of Commemorating the Dead Related to Adjustment Over Time?

John birrell.

1 Centre for Death and Society, University of Bath, Claverton Down, UK

2 Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands

Margaret Stroebe

3 Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands

Daniel Anadria

Cate newsom, kate woodthorpe, hannah rumble, anne corden.

4 Social Policy Research Unit, University of York, Heslington, UK

Yvette Smith

5 DignityUK, Sutton Coldfield, UK

Funeral services are known to serve multiple functions for bereaved persons. There is also a common, intuitively reasonable assumption of positive associations between engaging in funeral activities and adjustment to bereavement. We examined whether restricting ceremonial cremation arrangements to a minimum has a negative association with grief over time. Bereaved persons in the United Kingdom completed questionnaires 2 to 5 months postloss and again a year later ( N  = 233 with complete data; dropout = 11.4%). Neither type nor elaborateness of the cremation service, nor satisfaction with arrangements (typically high), emerged as significantly related to grief; no major subgroup differences (e.g., according to income level) were found. Results suggested that it does not matter to grief whether a more minimalistic or elaborate funeral ceremony was observed. We concluded that the funeral industry represented in this investigation is offering bereaved people the range of choices regarding cremation arrangements to meet their needs. Limits to generalizability are discussed.

There are considerable differences among bereaved persons in intensities of grief and the course of their adjustment over time. Researchers have therefore prioritized the examination of the so-called risk factors , ones which are associated with the development of higher levels and/or longer duration of grief. A major aim of such studies has been to identify those most likely to experience trouble during their grieving, in order to focus on persons at high risk (e.g., of complications in their grief/grieving process), to work toward lowering their suffering, and to enhance the provision of help where needed. Many potential risk/protective factors have been examined, including intrapersonal ones (e.g., personal circumstances prior to the death; kinship to the deceased), situational ones relating to the death itself (e.g., expected versus unexpected), or interpersonal ones (e.g., availability of social and emotional support). Despite this broad coverage, and the fact that there is extensive literature on funeral practices, the role of funeral ceremonies does not feature prominently, if at all, as reflected in systematic risk factor reviews (e.g., Burke & Neimeyer, 2013 ; Kristensen et al., 2012 ; Lobb et al., 2010 ; Stroebe et al., 2006 ). Nevertheless, there is widespread belief that participating in body disposal-related ceremonies actually helps one’s grief (cf. Lensing, 2001 ; Mitima et al., 2019 ), from which it could be surmised that minimal or no observance of funeral rites would have a negative impact on adjustment to the loss of a loved one.

It is possible that circumstances may prevail to limit funeral participation, in which case, if benefits are indeed to be gained by taking part in such ceremonies, detrimental effects could ensue. There have been significant changes in services provided by the funeral industry to meet with contemporary societal norms and consumer needs, some of which minimalize the nature of ceremonial events surrounding body disposal. To take the case of the United Kingdom (where the empirical study reported later was conducted): developments in funeral practices have been particularly manifest here. Most notably for the current interest, there has been a growing percentage of cremations in the British Isles to approximately 78% in 2018 ( The Cremation Society, 2019 ), and major changes have occurred in general in the provision of extended range of funeral options over recent years, partly—as a result of market and cultural transitions (a similar trend has been observed in the United States, cf. Beard and Burger 2020). These developments have been accompanied by an increase in the numbers of direct and unattended cremations ( Royal London, 2016 ). The funeral industry has responded to consumer demand by offering more affordable/simplified solutions, with 5% of consumers choosing a direct cremation funeral and direct burials, despite these not being a mainstream offering. These data and the broadening of the range of cremation options suggest that there is demand for nontraditional affordable funerals (cf. Royal London, 2016 ). Concern has been expressed about the loss of benefit to the bereaved through such reductions in ceremonials surrounding burial or cremation ( Birrell & Sutherland, 2016 ). It is thought that such options as direct cremation , with no attendance at the cremation and even perhaps without a memorial service, may indeed cost less—but actually come at a cost, diminishing opportunities for bereaved persons to take leave of the deceased in meaningful ways, ones that may serve to console and comfort family members and friends.

An underlying concern motivating our investigation was to examine whether contemporary changes in cremation practices which have been aimed in part to better-meet the needs of bereaved people could in fact have the paradoxical consequence of worsening the upset associated with bereavement. Empirical investigation can help clarify whether such concerns are justified. Therefore, the primary goal of the current project was to examine if funeral practices are a predictor of grief, by investigating connections between features of cremation and the experience of grief, specifically: Do the choices that bereaved persons make regarding their options for funeral arrangements relate to their course of grief and grieving?

Although the risk factor literature revealed little attention to the role of funerals, there is a burgeoning literature in the funeral domain which has provided relevant knowledge of use in designing our empirical study. We briefly review these sources next, covering background information on the range of body-disposal ceremonies; illustrating what is known in general about functions of funerals; and evaluating the extent to which empirical studies have provided scientific information on our research question. We make reference to studies of rituals too, since the topic of symbolic activities is clearly closely related to our research question, though it is not the focus of our own investigation.

Information deriving from a systematic literature search is summarized next. 1 As will become evident, the sources cover a wide range of studies and designs, qualitative and quantitative, large or small scale, descriptive or controlled, empirical research or more-theoretical, scholarly explorations.

First, there has been inventorization of the range of funeral practices (e.g., expansion of options). Dickinson (2012) reviewed the wide range of methods/memorializations and shifts to diverse contemporary trends and discussed the impact of change (e.g., cost-related ones). Walter et al. (2012) evaluated how the internet has changed the ways in which we die and mourn, considering how online practices may affect grief, thereby placing traditional practices in broader, contemporary perspective, including that of the social media (cf. Gibbs et al., 2015 ). Beard and Burger (2017) conducted a meta-analysis of U.S. studies inventorizing types of motives for changes in the industry: business-related versus consumer-related. While providing rich data for background understanding, the overview articles did not systematically review nor did the studies empirically examine the impact of body disposal ceremonies in direct association with adjustment to the loss of a close person.

Second, some studies have focused more specifically on issues surrounding funeral costs, difficulties, and—sometimes—adaptation . McManus and Schafer (2014) investigated the complex process underlying bereaved persons’ funeral expenditure, and its relationship with personal reactions (there was no quantification of specific psycho-social consequences). Kopp and Kemp (2007) examined the processes a consumer undertakes in making expensive decisions in stressful circumstances such as bereavement. Fan and Zick (2004) looked into the economic burden of funerals and burial expenses. Relatedly, Corden and Hirst (2013a , 2013b ) have reported on the costs and burdens of bereavement in general and funerals in particular. Most recently, Lowe et al. (2019) focused on changing and improving memorial services for the bereaved. Taken together, these studies inform readers of the broad spectrum of types of arrangements and potential (financial) burden for bereaved people. They are valuable for the identification of funeral-related difficulties, especially economic ones, and helpful in the construction of our questionnaire.

Third, some researchers have explored the functions of funerals . For example, Lensing (2001) looked at the role of the funeral service in providing support for the bereaved and their grief, listing many ways that assistance was provided. There is an extensive literature on effects of rituals (to which we turn for relevant but not direct evidence—these studies are not of funeral arrangements per se). In an unusual experimental study, Norton and Gino (2014) explored the role of rituals in mitigating grief, demonstrating that they alleviated grief, through the mechanism of regaining feelings of control. Vale-Taylor (2009) examined reasons for performing rituals, including those beyond the funeral ceremony per se. This branch of the literature includes both historical and recent comparative accounts, including cultural differences in body disposition and memorialization (e.g., Hunter, 2007 comparing United States with Peruvian functions of rituals; for international comparison: Valentine & Woodthorpe, 2013 ). There have been a number of studies on the use of rituals in grief therapy (e.g., empty chair, writing letters, especially for unfinished business and ambivalent relationships; saying goodbye rituals; cf. Castle & Philips, 2003 ; Rando, 1985 ; Reeves, 2011 ; Sas & Coman, 2016 ) most of which have been descriptive. For example, Doka (2012) affirmed the value of funerals in general and of rituals in therapy, arguing the benefits of involvement in planning and of active participation. Such studies demonstrate many and varied functions of funerals and rituals and attest to beliefs by the bereaved themselves and health-care professionals as to their benefits. However, causal relationships have not been established. Studies evaluating their efficacy are missing. For example, although claims have been made about the therapeutic value of rituals, to the best of our knowledge, no randomized controlled trial investigation has been conducted. Many claims are based on descriptive accounts. These are intuitively plausible, but not yet, to our knowledge, tried and tested.

Fourth, coming closer to current interests, there have also been studies of satisfaction and preferences in association with death-related (specifically, body-disposal) ceremonies . Key questions addressed have been whether rituals are perceived to be helpful (if so, in what respects?) and whether the arrangements are found to be appropriate and appreciated. Some authors give subjective evaluations of perceived benefits or usefulness based on cross-sectional and/or qualitative information (e.g., Bolton & Camp, 1987 , 1989 ; Castle & Phillips, 2003 ; Caswell, 2011 ; Servaty-Seib & Hayslip, 2003 ). For example, Servaty-Seib and Hayslip (2003) cross-sectionally examined the adjustment of adolescents and older persons following parental loss, finding that adolescents’ perceptions of the funeral reflected lower satisfaction and helpfulness, thereby addressing a question about subgroups: for whom do funerals help? (adolescents were less positive). O’Rourke et al. (2011) conducted a large empirical study which identified a number of predictors of satisfaction with funerals (e.g., religiosity). Of similar interest, Banyasz et al. (2017) looked into preferences for bereavement services, finding some differences in association with depression or complicated grief among the family members. In a small study, covering various durations of bereavement, Rugg and Jones (2019) examined what mattered to the bereaved regarding funerals. Although informative for both scientific and applied purposes, it must be noted that satisfaction with and/or preferences for funeral services/arrangements is a separate interest from establishing the relevance of cremation customs for adaptation in general and grief in particular: Establishing satisfaction with a service is not equivalent to assessment of its association with grief.

Finally, a few studies have directly addressed reactions to aspects of the funeral in relation to adaptation to the loss . Gamino et al. (2000) reported that those who found the funeral comforting and/or participated in planning showed less grief later on. There was indication that high scores on the measure of grief were associated with the occurrence of adverse funeral events (combined with not feeling comforted). Although this comes close to our research interest, the study had certain limitations. Importantly, it was conducted retrospectively, not prospectively, with assessment of the funeral taking place at the same—much later—time as the measure of grief intensity. Thus, it is likely that the negative perceptions about the funeral arrangements were colored by the high level of grief at the later time point when both of these were measured. Nevertheless, these authors drew attention to two potentially critical phenomena: They examined how funeral participation and the occurrence of adverse funeral events may be associated with grief adjustment and they pinpointed the possibility that if matters to do with the funeral go wrong, this may be associated with troubled grief. A longitudinal study conducted by Wijngaards-de Meij et al. (2008) examined the specific impact over time of circumstances surrounding death and burial. This investigation compared grief levels following cremation or burial. Similar levels of grief were found irrespective of the choice, as measured over time. In this study saying goodbye, presenting the body for viewing, was associated with lower levels of grief over time. One cannot conclude that saying goodbye reduces grief over time, but only that there is a significant relationship between these two variables.

The most recently published study revealed somewhat contrasting results to those mentioned earlier. Mitima-Verloop et al. (2019) examined the association between evaluations by bereaved people of the funeral (as well as their use of rituals), with their grief reactions. The investigation was longitudinal, and questionnaires were distributed at 6 months and 3 years postloss. Little impact of evaluations of the funeral (or rituals) with grief reactions was found: these body disposal-related customs were considered helpful, but there was no significant association with the bereaved participants’ grief reactions over the course of time. The authors pointed to the need for extended investigation. Of relevance here, dimensions of funerals were not examined in detail: Assessment was limited to four items covering general perceptions of the funeral ceremony (e.g., experiencing it as sad but positive, as important in processing the loss) and four items evaluating the funeral director (e.g., respectful, inspiring, decisive). Thus, our study has potential to build on this previous one.

In general, an extensive body of literature has accumulated on topics relating to the functions of funeral ceremonies (as well as those exploring purposes and practices of death rituals). Specifically for our interest, the literature search revealed studies of the variety and functions of funerals as well as studies indicating some benefits of specific rituals. However, few have actually addressed the question of a relationship between participating in funeral ceremonies with intensity and changes in levels of grief over time. In line with our conclusion, Mitima-Verloop et al. (2019) recently drew attention to the fact that very few empirical studies have examined the impact of performing rituals on recovery from the loss of a loved one, noting the paucity of studies examining whether a good farewell helps in coming to terms with the loss.

The Current Study

Our aim was to conduct a systematic, longitudinal, quantitative investigation of components of cremation services specifically (i.e., focusing on the arrangements which bereaved relatives choose to make) in relation to psychological adjustment (in terms of their levels of grief). We did so by examining bereaved persons’ decisions about constituent parts of the cremation which they had organized, and the relationships that these choices may or may not have on reactions to bereavement and the experience of grief and grieving over time.

The investigation was exploratory rather than hypothesis-testing in approach, since predictions could not firmly be made on the basis of earlier scientific studies. As indicated earlier, a couple of studies had shown that satisfaction with funerals, or specific features such as saying goodbye, was associated with lower levels of grief, but there was no research when we designed our study, which directly addressed the question of the impact of cremation arrangements on grief. Limited information from the more recent, well-designed Mitima-Verloop et al. (2019) study leads one—tentatively—not to expect close associations between cremation choices and grief reactions.

To achieve the goals outlined earlier, a questionnaire study was designed to examine features of cremation in relationship to grief over time, namely, at two time points, a year apart. Participants in the study, conducted in the United Kingdom, were selected on the basis of recency of bereavement and cremation, namely, 2 to 5 months prior to the start of the project. This study was part of a larger multiple method study into cremation and grief.

In February 2018, a small ( N  = 12) feasibility study was conducted, which indicated a response rate around 50%—after a follow-up phone call to nonrespondents—and no major issues with regard to the length, wording, content, and character of the questionnaire and the procedure.

On the basis of that, a mailing was carried out by DignityUK, a national provider of funeral arrangements, to 1,942 potential respondents in April 2018, which included detailed information about the study, a request for participation, an informed consent form to be signed by the participant in case of participation, a questionnaire and a prestamped return envelope, addressed to the research team. In accordance with General Data Protection Regulations, the mailing consisted of a brief explanatory letter from DignityUK enclosing a sealed envelope which contained detailed information, the questionnaires to be returned to the University of Bath. This way names and contact information became available only for those who agreed to participate in the study. All potential participants were clients or contact persons for clients of DignityUK. A follow-up letter was issued to those who had not responded after 4 weeks.

A valid response rate of 13.5% for the first data collection point (T1) was achieved ( N  = 263). While we had anticipated a higher response rate on the basis of the feasibility study—although the follow-up phone call may have boosted the response rate there—given that the participants were relatively recently bereaved (2–5 months), this response rate probably had to be expected. Reasons for nonparticipation are unknown to the research team; further investigation by contacting nonparticipants to establish these would have been ethically unacceptable.

Questionnaires for the follow-up data collection point (T2) were sent out in April 2019, exactly a year after T1, between 14 and 17 months after the loss, to all persons who participated in T1. The attrition rate turned out to be exceptionally low, with 247 participants having returned the filled out second questionnaire. Three were removed due to the late date of death at T1, and 11 were not processed in the analyses due to technical difficulties. The number of completers (i.e., participants who had sent in both the first and the second questionnaire) was 233, 2 rendering the effective attrition rate at 11.4%. Dropouts refer to the 30 participants whose T2 questionnaires were not received or included in the final, main analyses (comparisons were made between completers and dropouts, see Results section).

Questionnaires

Initially, the entire research team worked together to develop the T1 questionnaire, focusing mainly on the construction of a list of the key components of the cremation, and identifying major issues which can arise for a family as they face planning a cremation.

The T1 questionnaire consisted of four sections. The first section gathered demographic information, including factors which were seen as having a possible influence on decision making, such as income, education, religious commitment, and whether the participant had sought professional help in coping with their bereavement. The second section sought information about the deceased and the loss, addressing age, gender and cause of death, as well as the nature and perceived quality of the relationship between the deceased and the respondent. The third section addressed the funeral arrangements. This section addressed factual information as well as main aspects of the decision-making process and the respondent’s evaluation and feelings about the cremation, as well as possible regrets about the decisions that were made. The final section addressed the respondent’s experience of grief and grief-related health and other related psychological phenomena.

The T2 questionnaire contained changes in background situation since T1, a series of additional questions about the funeral ceremony and changes in the evaluation of the decisions surrounding the ceremony. The final section of the initial questionnaire was an integral part of T2, except for additional positively phrased items which were added, since participants commented on the T1 questionnaire having been slightly distressing.

The following measures are central to addressing the specific research question:

Components of the Cremation

An extensive series of questions covering relevant aspects about the cremation was compiled specifically for the purpose of this study by the research team. This covers the factual specifics of the cremation ceremony, interpersonal harmony/conflict in the decision-making process and overall satisfaction as well as satisfaction about specific components of the ceremony.

The category direct cremation (DC) was of special interest. DC was defined as the situation in which there was no attended service at the crematorium (with or without committal) and no service elsewhere with the coffin.

Inventory of Complicated Grief-Revised

The Inventory of Complicated Grief-Revised (ICG-r) is a 30-item measure of grief manifestations. The ICG-r has shown adequate psychometric properties ( Prigerson & Jacobs, 2001 ). Items represent separation distress symptoms (i.e., longing/yearning for the person who died), cognitive and emotional symptoms (including difficulties accepting the loss, avoidance, bitterness/anger), and functional impairment symptoms. The participants rated the occurrence of grief manifestations in the previous 3 weeks on 5-point scales ranging from 0 =  never to 4 =  always . The items were summed to form an overall grief severity score. 3

Participants

Demographic background.

The sample of 233 participants with complete data had a mean age of 64 ( SD  =   11), ranging from 20 to 88 years of age: 159 (69%) were female and 72 (31%) male (in 2 cases gender was not revealed). At T1, a total of 115 (50%) were married or lived together, 86 (37%) were widowed, 11 (5%) were separated or divorced, and 19 (8%) were single. Although most participants (224, 96.1%) reported no change in their marital situation between T1 and T2, 5 (2.1%) became widowed and 2 (0.8%) divorced or became single, and 1 (0.4%) participant married.

The mean number of people living with the participant at T1 was 0.8 ( SD =  0.9), ranging from 0 (43%) to 5 (0.4%). Most people ( n  =   111, 47%) shared a household with their partner, 45 (19%) with children, or with parents ( n  =   5, 2%), while 6 (3%) lived together with other relatives.

The majority of the participants ( n  =   148, 64%) considered themselves Christian. The second largest group ( n  =   53, 23%) said they had no religious affiliation, while some said they were agnostic ( n  =   7, 3%), atheist ( n  =   10, 4.3%), or humanist ( n  =   9 4%). Only 3 (1%) were Buddhist and none were Muslim (cremation is not a tradition within Muslim communities).

The highest level of education was some secondary school for 4 participants (2%); completed secondary school for 51 (22%); some college or university for 36 (16%), a college or university degree for 60 (26%), postgraduate degree for 28 (12%), and other professional qualifications for 52 (23%). Regarding the work situation, the majority ( n  =   142, 61%) was retired. A total of 43 participants (19%) were employed full-time, 30 (13%) part-time, and 9 (4%) were self-employed. Very few ( n  =   7, 3%) were homemakers and 1 (0.4%) was disabled. Between T1 and T2, a vast majority of 203 participants (87.1%) reported no change in their work situation. A total of 12 participants became retired (5.2%), while 14 (6%) became employed and 1 (0.4%) started a study.

Annual household income was divided in three categories: low (less than £26,000), middle (between £26,000 and £46,000) and high (higher than £46,000) on the basis of creating more or less equal size categories. Moreover, 42.2% fell in the low-income category, 31.8% in the middle category, and 26.0% in the high-income group. Of the low-income group, 39.5% suffered a drop of income after the loss, 37% did not face any change, while 23.5% saw the income increase after the loss. Of the middle-income group, these percentages were 23%, 52.5%, and 24.6%, respectively, and for the high-income category percentages were 14%, 56.0%, and 30.0%. The higher the income, the smaller the chance of suffering a decrease in income after the loss and the higher the chance of a financial increase after the loss, χ 2 (4) = 11.5, p  = .021.

The mean age of the deceased person was 81 ( SD  =   12), ranging from 30 to 102 years of age. The gender of the deceased person was almost evenly spread with 118 (51%) female and 113 (49%) male. In two cases, the gender of the deceased person was not revealed. Death occurred between August 1, 2017 and December 31, 2017. Cause of death most frequently was a longer illness ( n  =   140, 62%), followed by sudden illness or health problems ( n  =   65, 29%). Accidents caused the death of 4 of the deceased people (2%), while homicide and suicide both occurred only once. Some ( n  =   16, 7%) mentioned other causes, like negligence or multiple conditions causing death.

Most often, it was one of the parents of the participant who had died; for 79 participants (34%), it was the mother; for 38 (17%), it was the father who had passed away. In another 35% ( n  =   82), the partner had died; husbands for 58 participants (25%) and wives for 24 (10%). For 7 participants (4%), the deceased person was a sibling (4 brothers [2%] and 3 sisters [1%]). In 5 cases (2%), a child had died, which was in all cases a son. In addition, the death of 2 (1%) grandmothers and 2 friends (1%) were the reason for participation in the study. For 16 (7%) participants, the relationship was an aunt, uncle, cousin, in-law, or step-relative. Most participants considered themselves to have (had) a very close relationship with the deceased person ( n  =   201, 87%). Moreover, 24 (10%) participants considered themselves somewhat close and 6 (2.6%) said they were not very close (at all). Two participants did not report their level of closeness to the deceased person.

In 90% of the cases ( n  =   202), the participant was considered to be the next of kin of the deceased person.

The Cremation Service

A total of 19 (8%) of the participants signed the funeral contract on behalf of somebody else, mostly because of poor health ( n  =   11, 5%) or for practical reasons ( n  =   7, 3%). In 14 cases (5%), the primary bereaved person was too weak ( n  =   7, 3%) or too distressed ( n  =   6, 3%) at the time. In one case, there was no known relation. Slightly above a third of the participants ( n  =   81, 35%) managed the financial funeral arrangements themselves, 17 (7%) together with others, while in 6 cases (3%), others fully took care of the funeral arrangements.

Of the 233 participants who answered the questions about the cremation service, 216 (93%) made mention of a regular service at the crematorium with ( n  = 206, 88%) or without ( n  = 8, 3%) the coffin present, or elsewhere with the coffin present ( n  = 30, 13%), while 17 (7%) reported not to have organized such a service. The latter qualifies as an unattended or direct cremation in the original meaning of the word. This involved seven deceased partners, eight parents, and two other relationships.

Comparison of Completers and Dropouts

When compared to completers, dropouts showed no differences in age, t (258) = .100, p  =   .920, gender, χ 2 (1, 261) = 0.058, p  =   .810, and number of cohabitants, t (261) = −1.039, p  =   .300. Fisher’s exact test showed no differences in marital status ( p  =   .086), educational level ( p  =   .191), income ( p  =   .165), financial change since the loss ( p  =   .583), nor religion ( p  =   .274). There was a significant difference in work situation between the completers and dropouts ( F  =   11.3, p  =   .029), which is mainly due to disabled, self-employed, and part-time employed dropping out relatively more. With regard to the characteristics of the deceased, the two groups showed no difference in age, t (257) = 0.031, p  =   .975, and gender, χ 2 (1, 261) = 0.012, p  =   .911. Fisher’s exact test showed no differences in type of kinship to the deceased ( p  =   .428), closeness to the deceased ( p  =   .135), nor cause of death ( p  =   .815). At T1, no significant differences were found either in level of grief ( p  =   .998) between completers and dropouts. The general conclusion that emerges from these findings is that there are no major differences between those who dropped out of the study after T1 and those who completed it.

Levels and Changes in Grief Over Time

Levels of grief decreased modestly but significantly over time from an average of M  =   23.6 ( SD  =   21.2) at T1 to M  =   21.6 ( SD  =   19.6) at T2—Wilks = .97, F (214, 1) = 6.34, p  =   .013, η p 2  = 0.03. These mean scores represent an on-average relatively low ( normal ) level of grief among the participants at both data collection points. Female participants reported an approximately 5-point higher but not significantly differing, F (1) = 3.2, p  =   .08 ( η p 2 =0.015), level of grief both at T1 and T2. These levels decrease for men and women in similar ways—Wilks λ = 1, F (214, 1) = 0.051, p  =   .82, η p 2  = 0. There were no age differences (age groups 60 years and younger, 61–69 years, and 70+ years) in reported level of grief or change in level of grief. Grief was highest over loss of the partner (a considerable excess), compared to parents and other losses (e.g., children, siblings, grandparents, and friends-categories too small to be analyzed separately), F (2) = 21.2, p  =   .000, η p 2  = 0.165. And although Figure 1 does suggest grief levels decreased mainly among participants bereaved of their partners (both married and unmarried and living together), this interaction does not reach significance—Wilks = 1.84, F (215, 2) = 1.84, p  =  n.s .

ICG Scores by Lost Relationship.

In terms of causes of death, only losses due to long term illness and sudden illness were compared, since other causes of death were too rare among the sample. Participants bereaved through sudden death scored substantially higher on the ICG both at T1 and T2, F (1) = 9.905, p  =   .002, η p 2  = 0.049, and decreased in similar ways over time (see Figure 2 ).

ICG Scores by Cause of Death (Long vs. Sudden Illness).

We further analyzed possible effects of income and income change on levels and course of grief. This indicated no main effects due to income level, but did result in a main effect of change in household income on grief, indicating highest levels of grief at both T1 and T2 for those encountering income decrease, F (2) = 4.22, p  = .016. However, no interaction was found of level of income and changes in income after the loss on level or course of grief, suggesting that the effect of income change on grief was rather similar for all three income groups.

Traditional Versus Direct Cremation as Predictors of Grief

Comparing levels and course of grief between those who had a service at the crematorium or elsewhere with the coffin present and those who had a direct cremation, the former reported mean scores of 22.9 ( SD  =   21.6) at T1 and 21.0 ( SD =  19.7) at T2, while the latter reported 20.1 ( SD =  15.8) and 17.7 ( SD =  14.7), respectively. Neither the main effect of cremation service— F (1)=0.939, p  = .54, η p 2 =0.002—nor the difference in course turned out to be significant—Wilks F (1, 216) = 0.029, p  = .866, η p 2  = 0.000.

Looking at relevant background differences between DC’s and traditional cremations (e.g., age participant, age deceased, relationship with and closeness to the deceased, cause of death [e.g., long illness vs. sudden illness death] income, income change), no significant differences were found.

Decision Making Regarding the Funeral

Interpersonal conflict.

Most respondents found the process of decision making in the context of family and friends to be smooth; that is, there was little indication of conflict among the close persons involved. The five questions in T1 addressing this issue did not comprise a reliable scale, but looking at individual item level, it turned out, for example, that agreement about funeral arrangements was very high: 95% reported that friends and family were quite/very much in agreement and some 80% considered the planning smooth for those involved. Only higher levels of stress and tension in relationship to family and friends was positively correlated with level of grief at both T1 ( r  =   .33, p  =   .000) and T2 ( r  =   .30, p  =   .000).

Viewing of the Body

Participants were asked at T1 whether they chose to view the body. A total of 86 (38%) of the 227 having answered this question reported having viewed the body, while 141 (62%) did not, of whom 3 did not because it was not possible and 3 did not know whether it would have been possible. For only very few participants was it regarded as difficult to arrange viewing (0.9%). The motivation for viewing or not viewing the body was to preserve the memory of the deceased (4.0, SD  =   1.5 on a 5-point Likert-type scale) and second for saying goodbye (3.9, SD =  1.6) for 124 participants were motivated by the wish to say goodbye in one’s own way. Other reasons reported were worries about not being able to remember the deceased if the participant did not view (2.7, SD =  1.8), and worries about regretting it if one would have decided not to view the body (2.6, SD =  1.8). Obligation, social pressure and religious beliefs hardly played a role in the decision whether or not to view the body.

Partners who viewed the body reported higher levels of grief than partners who did not want to view the body even though that was possible, both at T1 (74.6, SD  =   24.5) versus 60.0 ( SD  =   18.2), t (57.5) = 2.9, p  =   .006) and T2 (68.2, SD =  20.0) versus (57.3, SD  =   16.9), t (74) = 2.6, p  =   .01. For those participants who lost a parent, viewing the body was not related to level of grief at T1 or T2. Satisfaction with the decision to view the body was not correlated with grief at T1 and T2 either ( r  =   .01 and .02, respectively).

Disposal of the Ashes

At T2, participants were asked about arrangements regarding the ashes, which were answered by 233 participants. Arrangements were made to bury or scatter the ashes with friends and family present by 69.7% ( n  = 109) of the participants, followed by 25.7% ( n  = 56) where the ashes were still retained by the family, and for 19.7% ( n  = 43), the ashes were scattered or buried without the presence of family and friends. 4 For 10 participants (1%), another arrangement was made or the participant did not know what was done with the ashes. Confined to a comparison of the first three groups, level of grief differed between the groups, both at T1 and T2, F (2) = 4.40, p  =   .14, with grief being highest for the participants, where the ashes were still retained by the family. Changes over time in grief followed a similar pattern for all three groups (Wilks λ = 0.978, F (2, 192) = 2.11, p  =   .123, see Table 1 .

Level of Grief by Arrangements for the Ashes.

Other aspects of the funeral ceremony were not investigated further in view of the patterns found for the aforementioned more obvious variables and given the need to be cautious about capitalizing on chance.

Satisfaction With the Funeral

This T1 scale contains seven items on a 5-point scale (α = .70). Examples of items are: “I felt the service was personal and appropriate for the person who died” and “I found the service helpful and/or consoling.” The range of the scale is 7 to 35, with higher scores indicating more satisfaction.

Participants turned out to be on average very happy with the funeral service. Mean score was 31.1 ( SD  =   4.1) on a scale of 35 maximally. Two thirds scored higher than 30 with nearly a quarter scoring the maximum amount. Level of satisfaction with the funeral turned out not to be related to levels of grief at T1 ( r  = −.02) or T2 ( r  = −.02). Comparing relatively low scores (29 and lower) with high scores (30 and higher) did not result in any differences in level of grief at T1 or T2 either. The separate specific item covering the overall satisfaction with the cremation day itself revealed no relationship with level of grief either (T1: r  =   .08; T2: r  =   .06).

We set ourselves the specific goal of examining the relationship between aspects of cremation and levels of grief over time. The results suggest that there are no particularly outstanding, notable or impactful relationships between aspects of cremation and levels of grief, nor in relationship to changes in levels of grief over a period as long as 1 year subsequent to the first time of investigation. The worry of funeral poverty , that bereaved persons would suffer more intensely as a result of cuts in ceremonial activities, has not been confirmed in this study. In this respect, the bereaved persons’ needs seem to have been well-met by the available offers of the funeral service providers. Among our participants, the majority was (very) positive about the funeral arrangements, whatever way they had organized the cremation service. Yet, any differences (and these were sufficient for investigation) in the actual arrangements or in the appreciation of different components of cremation, turned out to be unrelated to grief. The cremation ceremony itself was generally considered a meaningful and positive part of their arrangements for disposal of the body, but their specific, more or less positive evaluations were quite independent of personal reactions to loss of the close person. Importantly, although partners were grieving more intensely over their losses than adult children who had lost a parent, there were hardly any differences between these groups in how dimensions of cremation were related to grief. Yet one difference stood out: we noted that partners who viewed the body facilitated by the funeral director had higher T1 and T2 grief scores than those who chose not to (a difference not found for parents). Could it be that this funeral option provided the opportunity for those still grieving more intensely to take leave, to say goodbye? If so, this finding may again reflect the fact that the options available fit the needs of different subgroups of the bereaved clients.

In broader perspective, changes in provision of funeral services in this western society seem in line with contemporary needs of bereaved people: nowadays more options are available (and constantly developing). Our results showed that bereaved participants made use of a range of services, from those involving minimal to very extensive ceremonies. Reasons for making choices with regard to ceremonies are undoubtedly multiple and complex. But perhaps people (at least those subgroups represented by our participants) feel more freedom to make arrangements for disposal of the body in their own way these days. One could speculate that there may no longer be so much stigma to holding a minimal ceremony (in so far as it is well organized and conducted and not appearing to be cheap). On the other hand, there is evidence from funeral cost research that people still over-stretch themselves financially in selecting body disposal choices that they feel appropriate ( Corden & Hirst, 2013b ). We still have much to learn about the motives underlying choices in the face of diverse contemporary options.

There is no doubt that funerals serve many functions for bereaved persons, in keeping with the fact that such customs are incorporated into nearly all cultures of the world and across historical periods (cf. Hoy, 2013 ; O’Rourke et al., 2011 ). However, in terms of research findings, the results of our study endorse the recent conclusion of Mitima-Verloop et al. (2019) that, despite the intuitive assumption that funeral dimensions also contribute to grief adjustment, there is actually little association between aspects, perceptions and evaluations to do with the cremation and grief. That these results indeed indicate the relative unimportance of funeral components among risk factors for grief, also comes indirectly from findings that our participants did differ according to other, well-established risk factors, showing differences in directions typically found in reviews of the literature (e.g., sudden death or loss of a partner were associated with more intense grief over time than the relevant comparison groups).

A strength of this study is that the participants may be regarded as representing a normal segment of the population (naturally limiting the sample to those with a cultural background/tradition of cremation), as illustrated, for example, in the sociodemographic and grief-level details included in the Results section. As such, they seem to be rather typical of the range of clients encountered by funeral service providers. However, a minority of bereaved persons (approximately 10%, cf. Lundorff et al., 2017) suffer from complications in their grieving process. Our investigation did not focus specifically on this subcategory. It is possible that an important source of difficulties for a client diagnosed with complicated grief could relate back to adverse funeral events (e.g., if the disposal of the body were to be perceived as going severely wrong). Further investigation is needed to establish the extent to which such aspects play a part in complicated forms of grieving. Our results may also apply only to the type of western culture in which our study took place and not extend to those with very different funeral customs and rituals. They also relate to the free choices made by the bereaved and may not apply to situations such as a pandemic or other large-scale disaster, when the type of funeral may be imposed by circumstances or by government.

A weakness of the study is the low Time 1 response rate. Nor was it possible to compare participants and refusers, since for privacy reasons, we did not have any background information about the bereaved persons invited to participate in the study. The sample size did not permit unlimited analyses of subgroups of participants. Larger-scale studies need to replicate this investigation, extending to examination of potentially vulnerable subgroups (e.g., the impact of children’s attendance at funerals on grief over time). Nevertheless, we were able to compare groups according to their different choices and decisions regarding components of cremation. Furthermore, the extremely low attrition rate from T1 to T2 can certainly be considered a strength too, with the final sample size enabling us to conduct the statistical analyses we consider essential for addressing the research question.

A general cautionary remark is in order, about making inferences of causality. Even though few relationships and differences turned out to be significant, we need to be careful in interpreting any (lack of) differences in psychosocial functioning related to aspects of cremation in terms of causality. The study by Banyasz et al. (2017) on the use of bereavement-related services more generally is illustrative. Persons with depression and complicated grief reported greater willingness to use specific services such as a memorial website than those without. But: does one look at a memorial website a lot because one has these symptoms, or are these symptoms due to/intensified because of the (ruminative?) activity of looking so much at such websites?

Bereavement has been established as a life event associated with major, negative effects on mental and physical health and well-being ( Stroebe et al., 2016 ). Research is needed to understand precisely who is most at risk, and in the current context, to establish whether vulnerability was related to arrangements/choices made for disposal of the deceased’s body. This study was designed in the first place to inform policy makers and the funeral industry of possible impacts of changing cremation practices on bereaved persons. The results are on the one hand reassuring, but on the other hand, need replication and extension in the ways suggested earlier. Nevertheless, in due course, dissemination of knowledge from such projects should be able to guide policy and potentially contribute to the adaptation of bereaved people over time.

Finally, what is the (tentative) take-home message at this point in time? We noted in the Introduction that concern to investigate the research question about the connections between components of cremation and adjustment to bereavement was fuelled by the possibility that providing a wider range of (more minimal) services could potentially have a negative rather than the intended positive consequence for bereaved persons. We did not find this to be the case. Not only were there no systematic patterns of results indicating negative, harmful associations between dimensions of cremation and levels of grief over time, but clients seem to appreciate the available offers currently provided by the funeral services covered in our investigation, and to be able to use the available options in various ways, according to their personal preferences and needs.

Acknowledgments

The authors are grateful to DignityUK for funding this project and especially to Simon Cox, Head of Insight and External Affairs of DignityUK, for facilitating this research project in many ways.

Author Biographies

John Birrell : is a visiting research fellow at the Centre for Death and Society at the University of Bath. He has been actively involved in the development of bereavement care in Scotland for over 20 years and is an educator and policy consultant. His recent work has focussed on funeral policy and the need for support with costs for those on low incomes.

Henk Schut : is associate professor of Clinical Psychology at Utrecht University, the Netherlands. His research interests cover processes of coping with loss and the efficacy of bereavement care and grief therapy. He also supervises post-academic clinical psychologists in their research interests. With Margaret Stroebe he developed the Dual Process Model of Coping with Bereavement.

Margaret Stroebe : is professor Emeritus, working at the University of Groningen and Utrecht University, the Netherlands. She has specialized in the field of bereavement research for many years, collaborating with colleagues on theoretical approaches to grief and grieving, reviewing the scientific literature (e.g., in 3 handbooks), and conducting empirical studies (e.g., interactive patterns of coping).

Daniel Anadria : is an Excellence Programme BSc Psychology student at the University of Groningen, the Netherlands, with a previous publication in Psychiatric Quarterly on PTSD rates in therapists treating violent patients. He also works in the private sector as a data analyst. He hopes to follow an academic career after finishing his studies.

Cate Newsom : is a visiting research Fellow at the Centre for Death and Society at the University of Bath. She holds a PhD in clinical psychology from Utrecht University, where her research in the field of grief and trauma investigated the effectiveness of bereavement counselling interventions and care in the community.

Kate Woodthorpe : is a senior lecturer in Sociology in the Centre for Death and Society, Department of Social and Policy Sciences, University of Bath. She has conducted research on funeral practices and costs, mortuary services and cemetery usage. She has acted as special advisor to the UK Government on funerals.

Hannah Rumble : is a research fellow at the Centre for Death and Society, University of Bath. She is also a member of the editorial board for the journal Mortality and European Research Network on Death Rituals.

Anne Corden : is an honorary research fellow at the Social Policy Research Unit, University of York, UK, where she has many years’ experience of qualitative social research. Her work has spanned policy research in areas of income maintenance, health and welfare, and services for families and children. Most recently she has led a stream of research on experience of bereavement, with particular focus on the economic implications.

Yvette Smith : is research manager at Dignity Funerals, U.K. Dignity Funerals is a British run company; it is a large provider of funeral services and prepaid funeral plans in locations across the United Kingdom.

1 The literature search (using terms: Cremation or Funeral or Burial or Body disposal), conducted in 2017, identified 1,113 articles (book sources were searched by hand). Screening reduced the scope to approximately 70 articles, of which roughly 25% addressed the specific topic of funerals in relationship to adaptation. A search update in November 2019 yielded 51 new articles, of which 3 added particularly to this knowledge; one additional, highly important article was included subsequently.

2 Based on an expected overall difference over time of multiple indices of well-being, health, and functioning, a theoretically expected medium effect size ( f 2  = .15) for multiple linear regression analyses, and α and β of both 5%, the necessary number of participants with complete data for the project was 231 to analyze a maximum number of 20 predictor variables with this number of participants.

3 Multiple indicators of psychosocial functioning (e.g., general health, social support, social and emotional loneliness, grief rumination, life changes, and self-efficacy) were included for exploratory reasons, which are not reported here for lack of statistical power but resulted in similar findings to the ones presented.

4 Participants sometimes endorsed more than one subcategory within the 3 constructed groups, therefore the percentages do not add up to 100%.

Author Contributions

J. B., H. S., and M. S. developed the study concept. J. B., H. S., M. S., C. N., K. W., H. R., A. C., and Y. S. derived the empirical testing procedure. J. B., H. S., M. A., C. N., K. W., H. R., A. C., and Y. S. facilitated collection of the data. H. S., M. S., and D. A. processed the data and drafted the manuscript, with substantive expertise from J. B., C. N., K. W., H. E., A. C., and Y. S. All authors contributed to revisions of the manuscript and approved the final version for submission.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The research question has been formulated in close collaboration with DignityUK. The applied methods, results, and conclusions presented in this report have been established fully independently of the funding agency. Co author Y. S. of DignityUK facilitated the study by providing necessary data-access (confidentiality being observed), but did not participate in the design, analyses, or interpretation of the data.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research project was funded by DignityUK, Sutton Coldfield, UK.

Margaret Stroebe https://orcid.org/0000-0002-8468-3317

Hannah Rumble https://orcid.org/0000-0002-5410-8194

The funeral : the management of death and its rituals in a Northern industrial city

--> Naylor, Maura J.A. (1989) The funeral : the management of death and its rituals in a Northern industrial city. PhD thesis, University of Leeds.

This thesis explores the contemporary management of death in an urban setting. It provides a long overdue empirical re-appraisal of the way in which groups within society process the dead and continue to surround death with rituals. In particular, it addresses itself to a totally neglected area within British sociology, since the last major work, Geoffrey Gorer's Death Grief and Mourning in Contemporary Britain, appeared in 1965. Researcher presence a few hours after death had occurred and participant observation and interviews throughout the subsequent actions of the bereaved, funeral directors, clergy and others within the death system, illuminated the production of ritual from a number of different standpoints. This has thrown into relief, the ordinary 'common' or 'folk religious' understandings by which actors make sense of the trauma, as well as the official interests and constraints. There was substantial recourse to secondary data in occupational journals to cross check themes and inferences. The work takes account of the main theoretical perspectives within the literature which concentrate upon a perception of death as a 'taboo' subject, suggesting that modern society 'fears' or 'denies' it and that it has became 'dirty', 'medicalised' and 'invisible'. The thesis concludes that groups within the death system promulgate a number of differing orientations towards death so that it has been 'decontextualised' rather than denied and that there is 'ignorance' rather than 'fear'. There was an increasing trend towards the personalisation of ritual by the bereaved. This study contributes to the sociological understanding of funeral directors and clergy as occupational groups. It also goes beyond the narrowly economic critiques and surveys to reveal the nature of the relationships and work routines underlying the production of funeral ritual in the city. The information has important implications for decision makers within many areas of death and bereavement, particularly in the light of the recent Office of Fair Trading Survey (1989) which suggests that government intervention may be necessary within the Funeral Industry in order to achieve a better standard of service for the bereaved.

--> uk_bl_ethos_328979 --> -->

Filename: uk_bl_ethos_328979.pdf

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You do not need to contact us to get a copy of this thesis. Please use the 'Download' link(s) above to get a copy. You can contact us about this thesis . If you need to make a general enquiry, please see the Contact us page.

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Tomsk: Cultural treasure of central Siberia

Tomsk. Church of the Resurrection on Resurrection Hill. East view. September 24, 1999

At the beginning of the 20th century the Russian chemist and photographer Sergey Prokudin-Gorsky developed a complex process for vivid color photography. His vision of photography as a form of education and enlightenment was demonstrated with special clarity through his images of architectural monuments in the historic sites throughout the Russian heartland.

In June 1912, Prokudin-Gorsky ventured into Western Siberia as part of a commission to document the Kama-Tobolsk Waterway, a link between the European and Asian sides of the Ural Mountains. The town of  Tyumen  served as his starting point for productive journeys that included Shadrinsk (current population 68,000), established in 1662 on the Iset River. By the time of Prokudin-Gorsky’s visit, the town already had several enterprises, including a ceramics factory, and a population of some 15,000. 

Prokudin-Gorsky’s photographs of Shadrinsk include the rapid construction of pine log buildings for a railroad station complex – part of a secondary rail line built in 1911-1913. The partially completed buildings show an efficient use of standardized design, with measured log stacks in the foreground. Tall, spindly pine trees complete the picture.

Shadrinsk. Construction of standardized log buildings for a railroad station complex. Summer 1912

In a broader context, these photographs reflect the expansion of Russia’s rail system from Yekaterinburg to the Far East. Although Prokudin-Gorsky did not reach Tomsk (in central Siberia), I visited there in the late Summer of 1999 and saw the extensive use of log structures in an urban environment.

Tomsk beginnings

Tomsk. Church of Kazan Icon of the Virgin at Virgin-St. Aleksy Monastery, south view. Built in 1776-89; bell tower added in 1806. September 26, 1999

Archeological evidence suggests that Tomsk Region, part of the vast Ob River basin in central Siberia, has been settled for at least four millennia.

Epiphany Cathedral, southeast view. Built in 1777-84; expanded in 19th century; severely deformed in Soviet period for use as factory. This historic photograph shows the process of restoration, completed in 2002. September 25, 1999

By the time detachments of Russian Cossacks arrived in 1598, the native inhabitants included the Khants and Siberian Tatars, who, in 1603, accepted the authority of Tsar Boris Godunov.

In 1604, a fort was founded on the banks of the River Tom (a tributary of the Ob) and, throughout the 17th century, the Tomsk settlement served as a bulwark against the Kalmyk and Kirghiz steppe tribes.  

Church of the Resurrection on Resurrection Hill, north view. Built in 1789-1807; excellent example of "Siberian Baroque" architecture. September 26, 1999

With the expansion of Russian control to the south during the 18th century, the military significance of Tomsk was replaced by trade and transportation, centered on caravans of tea from China.

Former Stock Exchange Building, begun in 1825. September 25, 1999

The expansion of the Moscow Road through Siberia in the middle of the 18th century provided further stimulus for growth that was reflected in the construction of large brick churches, such as the Epiphany Cathedral (first completed in 1784) and the Church of the Resurrection (1789), a masterpiece of Siberian baroque architecture.             

Alexander Vtorov & Sons Building, Lenin Prospect 111. Built in 1903-05 as a department store & hotel; a major example of Art Nouveau architecture in Siberia. September 24, 1999

During the 1830s, the development of gold mines in the territory greatly increased the town's significance as a center of mining operations and administration. Tomsk Region also continued to serve as a place of political exile, as it had in the 17th and 18th centuries.             

‘Diverted’ opportunities

N. S. Zaslavsky "Fashionable Store," Lenin Prospect 105. Built in 1898-99; example of "Brick Style" commercial architecture. September 24, 1999

During the construction of the Trans-Siberian Railway at the end of the 19th century, Tomsk missed a second golden opportunity when the Ministry of Transportation decided to place the railroad crossing over the Ob’ River to the south. There are conflicting explanations for this decision, which slighted Tomsk, but created the town of Novonikolaevsk, subsequently to become the major Siberian metropolis of Novosibirsk.

Former building of the Flour Exchange, Lenin Square 14. Built in 1906-08; an example of Art Nouveau architecture. September 25, 1999

Tomsk settled for a branch line constructed in 1896 through the small junction of Taiga (80 kilometers south of the city) and that spur enabled Tomsk to remain a center of trade and agricultural development in central Siberia.             

Commercial building of A. V. Shvetsov, steamboat magnate. Built in 1882 in the "Pseudo-Russian" style (based on late medieval Russian architecture). September 25, 1999

The impressive scale of its commercial and residential architecture illustrates the diversity of Siberian culture at the turn of the 20th century. The Vtorov firm built one of Siberia’s largest department stores, which still graces Tomsk’s central district. Tomsk also became one of Siberia's preeminent educational centers, the location of Siberia's first university, founded in 1878. Among Russian institutions of higher learning, Tomsk State University is distinguished not only by its academic luster but also by its attractive, spacious campus.             

Main Building of Tomsk University. Built in 1885 in a late Neoclassical style. September 27, 1999

It should be emphasized that Tomsk accepted religious faiths in addition to Russian Orthodoxy. By 1910, the city had a Catholic Church of the Holy Rosary (now restored for use), two mosques (both of which have been restored), a Lutheran church (rebuilt), an Old Believer Orthodox church and a large synagogue that is among the most beautiful in Russia. The dome over its entrance has now been reconstructed.

Catholic Church of the Rosary of the Blessed Virgin. Consecrated in 1833 for the community of Polish exiles. Bell tower added in 1856. September 26, 1999

Architectural heritage

In 1911, the city’s northern area gained the neo-Byzantine Cathedral of Sts. Peter and Paul, the only church to remain open for most of the Soviet era. Some of the churches were built of wood, such as the Old Believer Church of the Dormition, completed in 1913 and lovingly maintained today by the parish. I was particularly honored to be asked to photograph Metropolitan Alimpy (Gusev; 1929-2003), who was visiting Tomsk at the same time.             

Choral Synagogue, Rosa Luxemburg Street 38. Built in 1902 to replace a wooden synagogue built in 1850. View before restoration of dome above main entrance. September 25, 1999

The most distinctive part of the city’s architectural heritage is displayed in its neighborhoods of elaborately decorated wooden houses, structures of solid logs often covered with plank siding.

Cathedral of Sts. Peter & Paul, southeast view. Built in 1909-11 in Neo-Byzantine style. September 24, 1999

It is no exaggeration to say that the "lacework" of Tomsk's wooden architectural ornament – particularly the window surrounds, or nalichniki – is unrivaled in Russia for its lavish detail and the extent of its preservation. Many of these extraordinary wooden houses were built for merchants who lived in the Tatar Quarter.  

Old Believer Church of the Dormition, southwest view. Wooden structure built in 1909-13 for the Old Believer Orthodox community in Tomsk region. September 27, 1999

The Tatar Quarter also contains the renovated White Mosque and a cultural center, located in a mansion built at the beginning of the 20th century for Karym Khamitov, a Tatar financial magnate.  Other ethnic groups include Russian  Germans, composed of settlers who moved to the area beginning in the 19th century. One of them was Viktor Kress, the governor of Tomsk Region in 1991-2012. 

Old Believer Church of the Dormition. Historic photograph of Metropolitan Alimpy (Gusev), spiritual leader of Russian Orthodox Old Believer Church. Photograph taken with the blessing of the prelate, who is standing in front of icon screen. September 27, 1999

Decline & rebirth

The many positive trends in the region’s development during the early 20th century were crushed by the savage fighting of the Civil War between 1918-1921. After that conflict, Tomsk entered a decline that was reversed by the evacuation to the city of industrial and research facilities during World War II.

Wooden house, Belinsky Street 19. Excellent example of "Carpenter Gothic" style. September 24, 1999

This momentum, reinforced by strong institutions of higher education in Tomsk, continued after the war with the development of nuclear research installations for both military and energy purposes.             

Wooden house built by architect Andrey Kryachkov. Fine example of Art Nouveau architecture in wood. September 26, 1999

With over a half a million inhabitants and a regional population of almost a million, Tomsk remains a leading Siberian center for administration, education, industry and energy resources.

Wooden house & courtyard gate, Tatar Street 46. One of many distinctive wooden houses built in the district of Tatar merchants. September 26, 1999

Protecting the environment has been a major concern, particularly in an area of stunning natural beauty. 

White Mosque, built in Tatar District in 1912-16. September 26, 1999

At the same time, dedication to the city’s historical environment – including its houses of worship – has succeeded in preserving an architectural legacy that represents a Russian national treasure.

House of merchant Karym Khamitov, built in Tatar District in 1894. Under conversion into cultural center for Tatar community of Tomsk region. September 25, 1999

Indeed, a walk through the historic neighborhoods of Tomsk reminds just how much Russian culture belongs to the forest.  

Ornamental wooden gate leading to courtyard of house on Solyanoi Lane 18. September 26, 1999

In the early 20th century, Russian photographer Sergey Prokudin-Gorsky developed a complex process for color photography. Between 1903 and 1916, he traveled through the Russian Empire and took over 2,000 photographs with the process, which involved three exposures on a glass plate. In August 1918, he left Russia and ultimately resettled in France, where he was reunited with a large part of his collection of glass negatives, as well as 13 albums of contact prints. After his death in Paris in 1944, his heirs sold the collection to the Library of Congress. In the early 21st century, the Library digitized the Prokudin-Gorsky Collection and made it freely available to the global public. A few Russian websites now have versions of the collection. In 1986, architectural historian and photographer William Brumfield organized the first exhibit of Prokudin-Gorsky photographs at the Library of Congress. Over a period of work in Russia beginning in 1970, Brumfield has photographed most of the sites visited by Prokudin-Gorsky. This series of articles juxtaposes Prokudin-Gorsky’s views of architectural monuments with photographs taken by Brumfield decades later.

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Local Footy

Life of local footy legend frank fopiani remembered in funeral service.

The life of local footy icon Frank Fopiani has been remembered at a funeral service, with his son Connor speaking glowingly about his father.

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Geelong local footy legend Frank Fopiani has been honoured by family and friends at a funeral service on Wednesday.

Fopiani tragically passed away last Monday from colorectal cancer just two months after being diagnosed.

His son Connor spoke about glowingly about his father, a loving family member who “touched the hearts of everyone he met with his love, kindness and generous spirit and joyous nature.”

Connor said it didn’t take long for him and his sister Paige to learn of his love for sport.

“He would often share memories of his past sporting achievements, which even included dominating his siblings and friends in backyard cricket and footy,” Connor said.

“Our fondest memories would always be waiting for dad to come home each day so that we could go for kicks – dad would always let Paige win though.

“Throughout the years we were lucky enough to watch him play footy and as we got older we learned just how good he really was.”

Affectionately known as ‘The Fop’ during his playing career, Fopiani was voted by the Geelong Advertiser as the best player of all-time in the Geelong Football Netball League.

He won seven premierships with North Shore and one with St Mary’s, winning three best-on-ground medals in grand finals.

His No.4 St Mary’s guernsey was laid out on his coffin along with a wedding photo with wife, Sylvia, and another picture of him with his two children.

Fopiani coached Connor through the grades at Newtown & Chillwell.

“He had an incredible ability to bring people together through sport, and I was lucky enough to have him as my own mentor and coach,” Connor said.

“He was there every step of the way, never missed a game and any question I ever had he has was there to guide to me be not only a better player, but person.”

Connor said their daily lives will never be the same after the death of their father, but noone will ever forget him.

“Mum and Dad’s love was pure and everlasting, and her heart will be his forever. They are true soulmates, and she will always be grateful for the life they shared together,” Connor said.

“Every single friend, every single family member and every single acquaintance will have their own special memories they shared with dad that they will cherish and remember always.

“Dad left a special mark in everyone’s lives that will never be forgotten.

Connor closed his touching tribute with a phrase that has been synonymous with Fopiani.

“This is not goodbye, this is just see you later. We love you more than words can say: ‘Can’t Stop the Fop’,” he said.

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GDFNL stats: The telling numbers in semi-finals’ wins

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Cinda "Cindy" L. Leisher

September 21, 1945 — august 29, 2024, chambersburg.

        Cinda (Cindy) Lee (Knoll) Leisher, 78, crossed over from this life into the arms of the Lord on Thursday, August 29, 2024. Cindy fought a very difficult battle with pancreatic cancer diagnosed in February.

        Cindy and her twin sister were the talk of the farming community when they were born on September 21, 1945, in Chambersburg Hospital. Their parents, Robert Knoll and Mabel Keller Knoll and big sister Margaretta were thrilled with the surprise of having two new babies born ten minutes apart becoming new additions to the family. 

       Mrs. Leisher attended Portico Elementary, Central and Faust Junior Highs, and graduated from Chambersburg Area Senior High School with the Class of 1963. During most of her working years, Cindy worked in various capacities in the Chambersburg School District. After clerical work at Forrester’s, the local hospital, and Franklin Feed and Supply, she joined the cafeteria crew and became head cook at Portico Elementary School, later at the middle school, the high school, and then finished her food career as head cook at J. Frank Faust Junior High School in 2007 adding up to 37 years with the district. During that time she probably roasted approximately 800 turkeys. Cindy also drove school buses for her dad and later for her husband, Harry. In Cindy’s spare time, she enjoyed teaching pre-school children for over 30 years in Sunday School at her home church of Salem United Brethren. She also loved to travel, enjoyed gardening and yard work, loved the music of Elvis, and relished the time spent with her family. Singing in the choir, harmonizing with her sister and joining in songfests with the rest of the family held a very special place in her life also.

       In addition to her parents, Cindy was preceded in death by her husband, Harry, who passed away in October 1982. Close family members mourning their loss but rejoicing in her new home are her son, Robert Leisher and his wife, Angela Smith Leisher, her oldest sister, Margaretta Knoll Young, (departed husband, Myron), her twin sister, Linda Knoll Taylor and husband Geoffrey.

       Funeral services will be held at 10:30 on Thursday September 5th, 2024 at the Salem United Brethren Church, 4349 Letterkenny Road, Chambersburg, where Pastor Chris Moore and Pastor Ron Cook will officiate. The family will receive friends Wednesday evening from 6:00 pm – 8:00 pm for the viewing at Thomas L. Geisel Funeral Home 333 Falling Spring Rd. Chambersburg. In addition, a second viewing will be held at the Salem United Brethren Church one hour prior at 9:30 am – 10:30 am. Interment will follow at 2:00 PM at Parklawns Memorial Gardens.

       Arrangements are entrusted to Thomas L. Geisel funeral Home where memorials and condolence may be made at our web site. Memorial contributions in the honor of Cindy’s life may be made in her name to the Salem United Brethren Church or Spirit Trust Hospice

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Cost and cost-effectiveness of multidrug-resistant tuberculosis treatment in Estonia and Russia

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This article has a correction. Please see:

• “Cost and cost-effectiveness of multidrug-resistant tuberculosis treatment in Estonia and Russia”. Katherine Floyd, Raymond Hutubessy, Kai Kliiman, Rosella Centis, Nina Khurieva, Wieslaw Jakubowiak, Manfred Danilovits, Genadi Peremitin, Salmaan Keshavjee and Giovanni Battista Migliori. Eur Respir J 2012; 40: 133–142. - September 01, 2012

Evidence on the cost and cost-effectiveness of treatment of multidrug-resistant tuberculosis (MDR-TB) is limited, and no published data are available from former Soviet Union countries, where rates of MDR-TB are highest globally.

We evaluated the cost and cost-effectiveness of MDR-TB treatment in Estonia and Russia (Tomsk Oblast), comparing cohorts enrolled on treatment according to World Health Organization (WHO) guidelines in 2001 and 2002 with cohorts treated in previous years. Costs were assessed from a health system perspective in 2003 US$; effects were measured as cures, deaths averted and disability-adjusted life-years (DALYs) averted.

Cure rates when WHO guidelines were followed were 61% (90 out of 149) in Estonia and 76% (76 out of 100) in Tomsk Oblast, with a cost per patient treated of US$8,974 and US$10,088, respectively. Before WHO guidelines were followed, cure rates were 52% in Estonia and 15% in Tomsk Oblast; the cost per patient treated was US$4,729 and US$2,282, respectively. Drugs and hospitalisation accounted for 69–90% of total costs. The cost per DALY averted by treatment following WHO guidelines was US$579 (range US$297–US$902) in Estonia and US$429 (range US$302–US$546) in Tomsk Oblast.

Treatment of patients with MDR-TB can be cost-effective, but requires substantial additional investment in tuberculosis control in priority countries.

• Cost-effectiveness
• multidrug resistance
• tuberculosis

The World Health Organization (WHO) estimates that ∼440,000 cases of multidrug-resistant tuberculosis (MDR-TB) develop each year [ 1 ]. Defined as resistance to at least the two most effective first-line antituberculosis drugs, rifampicin and isoniazid, cases of MDR-TB accounted for ∼5% of the ∼8.8 million new cases of tuberculosis that occurred in 2010 [ 1 ]. While India and China combined account for about half of the world’s estimated cases of MDR-TB, the highest rates occur in countries of the former Soviet Union (FSU): Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. In 2010, these countries had an estimated 66,000 cases of MDR-TB among reported tuberculosis patients (out of an estimated total of 290,000 cases among reported tuberculosis patients worldwide) and ranked first to 13th globally in terms of the percentage of tuberculosis cases with multidrug resistance, with figures of 9.4–26% among new cases and 24–65% among previously treated cases [ 1 ]. In 2010, the same set of countries notified ( i.e. reported) 33,000 cases of MDR-TB to WHO. In the three FSU countries with the largest populations (Russia, Ukraine and Kazakhstan), 14–18% of new tuberculosis cases and 44–46% of previously treated cases were estimated to have MDR-TB in 2010; 26,412 cases of MDR-TB were notified to WHO.

A 6-month course of first-line antituberculosis drugs can achieve cure rates of ∼90% in patients with drug-susceptible tuberculosis [ 1 ]. However, cure rates with the same regimen are much lower for patients with MDR-TB: 5–35% for previously treated cases and 12–60% for new cases [ 2 ], with a relapse rate of 24% [ 3 ]. Death and treatment failure rates for people with MDR-TB are correspondingly high. Treatment that includes second-line antituberculosis drugs can considerably improve cure rates [ 4 – 16 ], but takes longer, causes more side-effects, requires more complex regimens and has a much higher cost [ 17 – 20 ].

WHO and partner agencies have developed guidelines for the treatment of MDR-TB using first- and second-line drugs, most recently in 2011 [ 17 – 20 ]. Key elements include diagnosis based on culture and drug susceptibility testing (DST), treatment with second- as well as first-line drugs for at least 20 months, and standardised recording and reporting of treatment outcomes. Projects or programmes that have followed these guidelines in Estonia, Latvia, Peru, the Philippines and Russia have achieved cure rates of 60–75% [ 21 ].

Data on cost and cost-effectiveness are needed to assess whether investment in MDR-TB treatment is justified compared with competing health sector priorities as well as to develop appropriate budgets for implementation if treatment is scaled up. To date, published studies are limited to Peru and the Philippines [ 4 , 22 , 23 ]. In this article, we present data on the cost and cost-effectiveness of MDR-TB treatment according to WHO guidelines in Estonia and Russia (Tomsk Oblast) from two studies initiated in 2002 and completed in 2006.

Russia had a population of 143 million in 2010 [ 1 ], a reduction from 146 million in 2001. The number of tuberculosis cases notified to WHO in 2010 was 163,000, with a relatively stable notification rate (per 100,000 population) during the decade 2001–2010 [ 1 ]. The estimated number of MDR-TB cases was 40,000 in 2010, third only to China and India [ 1 ]. Administratively, the country is divided into 88 oblasts. Tomsk Oblast is in Siberia, with a land area similar to that of Poland and a population of 1.1 million. The WHO-recommended approach to tuberculosis control was introduced in 1997.

Estonia is among the smallest of the FSU countries with a population of 1.3 million in 2010 [ 1 ]. In the decade 2001–2010, the number of notified TB cases fell from 708 in 2001 to 283 in 2010, while the number of cases of MDR-TB was around 60 to 90 each year [ 1 ]. The DOTS strategy has been implemented countrywide in Estonia since 1999.

Estonia and Russia are both middle-income countries, with per capita incomes of US$4,450 and US$1,780, respectively, in 2001, and US$14,370 and US$9,910, respectively, in 2010 [ 24 ].

MDR-TB diagnosis and treatment: pre- and post-adoption of WHO guidelines

Management of MDR-TB before and after the introduction of WHO guidelines was similar in Tomsk Oblast and Estonia. Before WHO guidelines were adopted, all TB cases were routinely tested for MDR-TB. Treatment for MDR-TB was determined by individual physicians, who were often constrained by the limited availability of second-line drugs as well as incomplete information about a patient’s susceptibility to first- and second-line drugs (while resistance to isoniazid and rifampicin was confirmed for all patients, data on resistance to other first- and second-line drugs was sometimes lacking). Surgery sometimes formed part of the treatment. Patients were almost always hospitalised throughout treatment and discharged when cavity closure was documented.

With the introduction of treatment for MDR-TB according to WHO guidelines (January 2001 in Tomsk Oblast and August 2001 in Estonia), management of patients with MDR-TB changed substantially. All cases diagnosed with MDR-TB were considered for treatment by a small expert committee (“consilium”) of four or five physicians, including both tuberculosis and public health specialists. This committee determined which patients should be enrolled, the treatment regimen and whether patients should be treated in hospital or as an outpatient. In Estonia, the exclusion criteria defined by the expert committee were a diagnosis of AIDS and a history of repeated default. In Tomsk Oblast, the expert committee used more exclusion criteria, including the presence of another life-threatening condition, high likelihood of default, patient unwillingness to be enrolled and a DST pattern that suggested treatment would fail (however, as illustrated in the Results section, almost all enrolled patients were resistant to three or more drugs and DST patterns were similar to those among patients enrolled on treatment prior to the adoption of WHO guidelines). In Tomsk Oblast, shortages of drugs during the study period also meant that priority was given to the patients who were most seriously ill. It was beyond the scope of our study to assess what happened to those patients who did not meet the inclusion criteria, although we acknowledge that they would have been a source of further transmission of tuberculosis in the community.

After the introduction of WHO guidelines, treatment regimens in both Estonia and Tomsk Oblast were designed based on DST results for first- and second-line drugs, and typically included six or seven drugs in the intensive phase of treatment, including a second-line injectable and any first-line drugs to which the patient was susceptible. Laboratory tests in Estonia in 2001 and 2002 were quality-assured by laboratories in the UK and Germany as well as by a supranational reference laboratory in Sweden. External quality assurance for the laboratory in Tomsk Oblast was provided by the Massachusetts State Laboratory Institute in Boston, MA, USA; this laboratory is part of the supranational laboratory network. In the 12–18-month continuation phase of treatment, started 6 months after conversion to culture-negative status, the injectable drug was removed from the regimen. All treatment was provided under direct observation. Transport vouchers and food packages were given to outpatients in Estonia, and food parcels or free provision of meals were provided at outpatient facilities in Tomsk Oblast. Clinical and laboratory staff in both settings were trained through international and national courses, and in Tomsk Oblast, technical assistance was provided on a regular basis by Partners in Health (a nongovernmental organisation headquartered in Boston). Patient progress was monitored using periodic radiography, and monthly sputum and culture examinations. A small management team was established to provide overall supervision of clinical and laboratory work, and to maintain a tuberculosis register in which data on patients, including their treatment outcomes, were recorded.

Patient cohorts studied

For treatment according to WHO guidelines, we considered the cohorts enrolled in the first 12–19 months after WHO guidelines were adopted. The time period was from January 1, 2001 to July 31, 2002 (19 months) in Tomsk Oblast and from August 1, 2001 to July 31, 2002 (12 months) in Estonia. For the period prior to the adoption of WHO guidelines, we considered a cohort of patients enrolled from July 1998 to December 1999 in Tomsk Oblast and a 3-yr cohort enrolled in south Estonia from 1995 to 1997. The Estonian cohort was selected because clinical records were still available and, with DST conducted in a supranational reference laboratory in Sweden, a diagnosis of MDR-TB was considered reliable.

Treatment outcomes

Treatment outcomes were assessed using internationally agreed consensus definitions [ 25 ]. There were six possible outcomes: cured, completed treatment, died, defaulted, transferred out of the district with treatment outcome unknown and failed treatment.

Cost and cost-effectiveness analysis

Any cost-effectiveness analysis requires comparison of relevant alternative strategies [ 26 ]. We compared treatment for MDR-TB according to WHO guidelines with treatment before these guidelines were adopted (as described above). Costs for both strategies were assessed from a health system perspective in 2003 US$ (the year in which most patients completed their treatment), using standard methods [ 26 – 28 ]. Patient costs were not considered because it was impossible to establish these costs in the period prior to the adoption of treatment according to WHO guidelines. In addition, after WHO guidelines were adopted, costs to patients were small. In Estonia and Tomsk Oblast, costs that are often borne by patients in other countries became the responsibility of the health system ( e.g. transport costs, which were covered by vouchers in Estonia).

Two types of costs were considered: 1) the average cost of individual components of treatment ( e.g. drugs or a visit for directly observed treatment); and 2) the average cost per patient treated. The costs of individual components of treatment were calculated using an “ingredients” approach, i.e. the quantity of resources used was multiplied by unit prices. Joint costs ( e.g. staff that spent time on tuberculosis patients on first-line treatment for drug-susceptible tuberculosis and patients being treated for MDR-TB) were allocated according to the time spent on each group of patients. Vehicle and equipment costs were annualised using current replacement prices, the assumption of a 5-yr life expectancy and a discount rate of 3% [ 26 – 28 ]. Start-up training costs were annualised over 3 yrs. Building costs per year were based on rental values per month. All local costs were converted into US$ using the average exchange rate in 2003 (US$1 was equivalent to 14.7 Estonian kroons or 34.8 Russian roubles). The average cost per patient treated was calculated as the cost of each treatment component multiplied by the average number of times this cost was incurred. Sources of data included expenditure records, interviews with staff and patients, project records and databases, and clinical records. The social insurance system was also a source of data on the unit prices of several components of care in Estonia ( e.g. the cost of different types of laboratory test and the cost of a bed-day in hospital). Data on the cost of second-line drugs were collected from national sources and from the Green Light Committee (GLC). The GLC was a mechanism established by WHO to help countries to access second-line drugs at the lowest possible price, and it helped to supply second-line drugs to Estonia and Tomsk Oblast in the years after WHO guidelines on MDR-TB treatment were adopted.

There was uncertainty about several parameters that influence the effectiveness of treatment for MDR-TB, which in turn affected estimates of both total costs and cost-effectiveness. The effectiveness, cost and cost-effectiveness of treatment for MDR-TB after WHO guidelines were adopted, compared with the pre-guidelines period, was therefore estimated as part of a multivariate uncertainty analysis. For consistency and comparability, this analysis was based on the same principles and much of the data that were used in previously published evaluations of MDR-TB treatment in Peru and the Philippines, full details of which are available elsewhere [ 4 , 22 ] and in the online supplementary material. In brief, the analysis was designed to measure the effectiveness of treatment for MDR-TB in terms of cases cured, deaths averted and disability-adjusted life years (DALYs) averted, and to capture both: 1) effects among the patient cohort treated, and 2) the effect of treatment of this cohort on transmission, and hence the number of cases, and deaths and DALYs averted that occur in the future. A Microsoft® Excel™ (Microsoft Corp., Redmond, WA, USA) spreadsheet model was used in which treatment paths were defined for the same patient cohort ( i.e. 149 patients in Estonia and 103 patients in Tomsk Oblast) for the two alternative strategies, i.e. treatment for MDR-TB before and after WHO guidelines were adopted (the analysis was undertaken for the same number of patients to avoid distortions caused by different numbers of patients in the cohorts considered before and after the introduction of WHO guidelines). The number of patients following each treatment path, together with their associated costs and effects, was then defined according to: 1) the parameters, parameter distributions and data sources listed in the online supplementary material [ 29 – 37 ]; 2) the costs per patient before and after the adoption of WHO guidelines, reported in this article; and 3) treatment outcomes before and after the introduction of treatment according to WHO guidelines, also reported in this article. A Monte Carlo simulation involving 5,000 iterations was used to estimate means and lower and upper bounds (fifth and 95th centiles) for the main outputs of interest, i.e. total costs and total DALYs lost for each strategy, total DALYs averted by treatment according to WHO guidelines, and the cost per DALY averted by treatment according to WHO guidelines.

Statistical analysis

We compared the clinical, socioeconomic and demographic characteristics of the patient cohorts treated before and after the introduction of treatment for MDR-TB according to WHO guidelines, and also compared the cohorts treated after the introduction of WHO guidelines in Estonia and Tomsk Oblast. We used Chi-squared tests for comparisons of categorical outcome variables. We also used the Chi-squared test to compare the treatment outcomes of chronic cases, new cases and re-treatment cases.

Patient enrolment and characteristics

The clinical, socioeconomic and demographic characteristics of the patients treated for MDR-TB before and after the introduction of WHO guidelines in Estonia and Tomsk Oblast are summarised in table 1 (further details are available from the authors upon request). For the patient cohorts enrolled after the introduction of WHO guidelines, the numbers of patients considered eligible, enrolled on treatment and considered in our analysis are summarised in figure 1 .

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a) Patient enrolment in treatment according to World Health Organization (WHO) guidelines in Estonia from August 1, 2001 to July 31, 2002. b) Patient enrolment in treatment according to WHO guidelines in Tomsk Oblast, Russia from January 1, 2001 to July 31, 2002. # : re-treatment cases are patients who had been treated for tuberculosis (TB) before and who had failed or defaulted from the treatment regimen; new cases were patients who had not been previously treated for TB. ¶ : there were 1,314 patients identified with multidrug-resistant (MDR)-TB during the study period. The large difference between this number and the 124 patients who were considered eligible was due to several factors. Anyone with severe concurrent pathology ( e.g. diabetes, severe mental pathology or ulcer) was excluded, as were pregnant females. Rural residents were enrolled only if they lived in an area where a health worker was available to oversee treatment after discharge from hospital. Given the limited supply of second-line drugs, priority was given to patients whose condition was life-threatening. The programme was new and unproven, and not all cases were willing to consider treatment in it. Staff capacity was also a limiting factor, as there was a shortage of physicians considered to have the necessary competence to treat and manage side-effects associated with second-line drugs. + : chronic cases are patients who had already received at least two treatments with first-line drugs (a treatment regimen for a new case and a re-treatment regimen); re-treatment cases are patients who had been treated for TB before and who had failed or defaulted from the treatment regimen; new cases were patients who had not been previously treated for TB.

From August 1, 2001 to July 31, 2002, 173 cases were diagnosed with MDR-TB in Estonia, of whom 149 were enrolled on treatment according to WHO guidelines ( fig. 1a ). The average age of patients was 45 yrs and most were males (109 (73%) out of 149). Alcohol abuse and unemployment rates were high (30% and 42%, respectively), and patients had severe drug resistance (79% were resistant to five or more drugs). Among the 54 patients with MDR-TB treated before the introduction of WHO guidelines in Estonia, 63% were male. The age distribution was similar to the patient cohort treated according to WHO guidelines, but the rate of alcohol abuse appeared to be lower (p=0.01 when those for whom no data were available were excluded) and fewer cases were from urban areas (p=0.005). Most strikingly, there was less severe drug resistance (p<0.001), with only 4% of patients resistant to five or more drugs. Overall, ∼60% of patients were tested for HIV in Estonia and one was HIV positive.

In Tomsk Oblast, 124 patients were considered eligible for treatment for MDR-TB according to WHO guidelines ( fig. 1b ). Of these, we considered the 100 out of 105 patients from the civilian sector for whom detailed data on their treatment could be retrieved. We were unable to obtain permission to collect data from the prison sector. The average age was 38 yrs and 70% of patients were male. As in Estonia, unemployment and alcohol abuse rates were high. Drug resistance was less severe than in Estonia (29% of patients were resistant to five or more drugs), but 98% of patients were resistant to three or more drugs.

In the cohort treated before the introduction of treatment according to WHO guidelines, 83% of patients were male and the average age was 46 yrs, both significantly higher than the cohort treated after WHO guidelines were followed ( table 1 ). There were no statistically significant differences between the cohorts for the other variables that we studied, except for the rate of alcohol abuse, which was higher in the cohort treated before the introduction of treatment according to WHO guidelines (p=0.04). Representative data on HIV status were not available.

Treatment outcomes are shown in tables 2 and 3 ]. For the cohorts treated according to WHO guidelines, the cure rate was 76% in Tomsk Oblast and 61% (including patients that completed treatment) in Estonia. In the cohorts treated before the introduction of WHO guidelines, the cure rate was 15% in Tomsk Oblast and 52% in Estonia. The death rate in Tomsk Oblast before WHO guidelines were adopted was high, at 67%, and the remainder of patients (17%) failed treatment. Within the cohort treated according to WHO guidelines in Estonia, failure rates were lower but default rates higher among new cases compared to previously treated cases; in Tomsk Oblast, cure rates were lower and default rates higher in new cases compared with previously treated, chronic cases (p=0.01).

Cost and cost-effectiveness

The average cost per patient treated according to WHO guidelines (in prices for 2003) was US$8,974 in Estonia and US$10,088 in Tomsk Oblast. This was considerably more than costs in the period before WHO guidelines were used, which were US$4,729 in Estonia and US$2,282 in Tomsk Oblast ( table 4 ). Drugs and in-patient care were the most important costs in both cohorts and in both sites; when combined, they accounted for 69–90% of total costs. The drug regimens used in Tomsk Oblast when WHO guidelines were followed were more expensive than those used in Estonia, at US$3,718 compared with US$2,219 per patient.

The total costs for each strategy, including both the costs of the cohort enrolled and the costs associated with secondary cases generated through transmission of tuberculosis by this cohort, are shown in table 5 . The net increase in total costs associated with treatment for MDR-TB according to WHO guidelines was about US$0.5 million (range US$0.4–US$0.6 million) in Estonia and US$1.0 million (range US$0.9–US$1.1 million) in Tomsk Oblast. These additional costs resulted in a large number of averted deaths and DALYs ( table 5 ). The mean cost per DALY averted by treatment according to WHO guidelines was US$579 (range US$297–US$902) in Estonia and US$429 (range US$302–US$546) in Tomsk Oblast.

The total funding required for treatment according to WHO guidelines of all registered cases of MDR-TB in 2003 was about US$1.3 million in Estonia and US$375 million in Russia when the costs in Tomsk Oblast are extrapolated to the whole of the country ( table 6 ).

The cost of providing treatment for patients with MDR-TB according to WHO guidelines in Estonia and Russia (Tomsk Oblast) was about US$9,000–US$10,000 per patient treated (in prices for 2003), with the dominant cost items being second-line drugs and hospitalisation (averaging >6 months). This was about twice the cost of the treatment previously available in Estonia and four to five times the cost of the treatment previously available in Tomsk Oblast. The increase in costs was accompanied by a substantial improvement in the cure rate in Tomsk Oblast (76% compared to the previous 15%) and a smaller improvement in Estonia (61% versus 52%). The cost per DALY averted was about US$400–US$600.

Previous studies of the cost and cost-effectiveness of treatment for MDR-TB in low- and middle-income countries are limited to Peru and the Philippines. The cost of MDR-TB treatment in these countries was low compared with Estonia and Tomsk Oblast, at US$2,500–US$3,500 per patient [ 4 , 22 ]. Almost all of the difference was explained by the high cost of hospitalisation in Estonia and Tomsk Oblast, at US$4,491 and US$3,341 per patient, respectively, compared with US$107 in the Philippines, and no hospitalisation in Peru. Drug costs were also higher, particularly in Tomsk Oblast (US$3,718 per patient versus US$2,219 in Estonia, US$1,557 in the Philippines and US$824 in Peru), which can be explained by more severe patterns of drug resistance, including to second-line drugs [ 4 , 22 ]. The cost per DALY averted was two to three times higher than the approximately US$200 reported in the two studies from Peru and the Philippines, which used the same methodology for cost-effectiveness analysis. A more recent study from Peru [ 23 ] also produced similar results to our study for a strategy in which multidrug-resistance testing is conducted among all patients that had already received at least one course of tuberculosis treatment with first-line drugs, provided allowances are made for methodological differences (such as the number of years of life gained per death averted). However, results for a theoretical strategy in which all tuberculosis cases are tested for multidrug resistance, an approach which is directly comparable to the strategies implemented in practice in Estonia and Tomsk Oblast, were different. For Peru, this strategy was estimated to cost US$2,731 per quality-adjusted life-year gained, much more than we have estimated for Estonia and Tomsk Oblast. The explanation for this much higher figure is that compared with Estonia and Tomsk Oblast, Peru has much lower rates of multidrug resistance among new tuberculosis cases, the ratio of costs with multidrug-resistance testing to costs without multidrug-resistance testing is much higher, and better treatment outcomes for multidrug-resistant cases are achieved in the absence of treatment with second-line drugs [ 1 , 2 , 23 ].

Differences in the cure rates achieved in Estonia and Tomsk Oblast when WHO guidelines were adopted were mainly due to higher default and death rates in Estonia. The higher death rate in Estonia may be due to more severe patterns of drug resistance, which itself might reflect the after-effects of suboptimal treatment in the period before WHO guidelines were adopted as well as the less stringent enrolment criteria that were applied. The higher default rate is harder to explain; possible risk factors, such as unemployment and alcohol abuse, were present to a similar degree in both cohorts, and social support to encourage treatment compliance was available in both settings. A plausible explanation is that stricter enrolment criteria were used in Tomsk Oblast. The particularly high death rate in Tomsk Oblast before WHO guidelines were adopted is comparable to the natural history of disease, illustrating the low efficacy of treatment at that time.

Our study has several limitations. There were differences in the socioeconomic, clinical and demographic characteristics of the cohorts treated in the period before and after the adoption of WHO guidelines for the treatment of MDR-TB. In Estonia, there were lower rates of unemployment and alcohol abuse, and less severe patterns of drug resistance in the cohort treated before WHO guidelines were followed and, as a result, we may have underestimated the improvement in health outcomes associated with treatment according to the WHO guidelines in this setting. In Tomsk Oblast, a large number of patients were eligible for treatment but not enrolled. This could lead to over- or underestimation of the increased effectiveness associated with the introduction of WHO guidelines. The fact that priority was given to the most severely ill patients would tend to underestimate the effectiveness of treatment according to WHO guidelines, although the cure rates achieved were high. Both settings have a population of ∼1 million people, so the results apply to treatment that is provided on a relatively small scale. We did not collect data on costs to patients in either setting, since reliable data could not be obtained retrospectively for those patients treated before the WHO guidelines were adopted, and in Tomsk Oblast, we also lacked data on rates of HIV infection and data for patients treated in the prison sector.

Perhaps the most obvious limitation is that the data are relatively old, from patients started on treatment in 2001 and 2002. This is due to delays in finalising the results in the format of a paper for publication in a peer-reviewed journal. Nonetheless, the data are as recent as any other published data on the cost and cost-effectiveness of treatment for MDR-TB in low- and middle-income countries, and the numbers of cases of MDR-TB in 2010 were broadly comparable to numbers in 2001. Although recent analyses of the cost of second-line drugs and the regimens used in Estonia and Tomsk Oblast suggest that the cost of the regimens used in 2001–2002 remained at similar levels in 2010 (data not shown), two principal changes have occurred or are likely to have occurred in the years since the data were collected. First, some of the costs associated with treatment are likely to have increased, notably costs (such as those of staff providing care in outpatient facilities or on hospital wards) that are closely related to income levels. Average gross national income (GNI) per capita almost doubled in Estonia and almost tripled in Russia between the end of 2003 (the year for which we estimated costs in US$) and 2010, reaching US$14,370 in Estonia and US$9,910 in Russia in 2010 [ 24 ]. Secondly, the funding available for tuberculosis control in both countries grew, especially in Russia. On the assumption that the cost of the drug regimens has remained unchanged (as suggested by analysis of the cost of the regimens used at current prices quoted by the GLC; data not shown) but that other costs have increased in line with the growth in incomes per capita , the cost per patient treated in 2010 would have been US$20,910 in Estonia and US$22,512 in Russia, and the cost per DALY averted would be US$692–US$2,101 and US$674–US$1,218, respectively. Funding for tuberculosis control increased more than the estimated growth in costs in Russia, reaching US$1.3 billion in 2010. Although the total funding available for tuberculosis control in Estonia was not available, the funding available for second-line drugs had increased to approximately US$3,500 per patient.

The strengths of this study include the collection of detailed data on health services utilisation, costs and treatment outcomes for MDR-TB cases for all patients, and that this is the first study to provide evidence about the cost and cost-effectiveness of treatment for MDR-TB according to WHO guidelines in FSU countries, the part of the world where the problem of MDR-TB is most severe. The results from Tomsk Oblast may be broadly generalisable to other parts of Russia, given a common approach to tuberculosis control across the country, and results from Estonia may be generalisable to the two other Baltic countries (Latvia and Lithuania). Results from Tomsk Oblast also have broad relevance to other FSU countries, given similar levels of drug resistance and comparable models of care that remain largely hospital based.

Our results suggest that treatment for MDR-TB according to WHO guidelines can be cost-effective in both Estonia and Russia. The cost per DALY averted in both settings was much less than per capita gross domestic product, a threshold that WHO has used to define interventions that are “highly cost-effective” [ 38 ]. This would remain the case even if the nondrug costs of treatment have risen in line with GNI per capita since the time the study data were collected. However, expanding treatment according to WHO guidelines to all cases of MDR-TB in FSU countries will require a big increase in funding. In the Global Plan to Stop TB from 2011 to 2015, the cost of such expansion has been projected at US$3.5 billion over 5 yrs, increasing from US$0.6 billion in 2011 to US$0.8 billion in 2015 [ 39 ], compared with reported funding of US$259 million in 2011 [ 1 ].

Overall conclusions

Treatment of patients with MDR-TB can be cost-effective in Estonia and Russia, and results may be broadly generalisable to neighbouring European countries with a high burden of MDR-TB. Scaling up MDR-TB treatment in the 18 priority countries of the WHO European Region in line with targets set in the Stop TB Partnership’s Global Plan to Stop TB for 2011–2015 [ 39 ] will require a substantial increase in funding for tuberculosis control.

• Acknowledgments

We thank C. Fitzpatrick (Stop TB Dept, World Health Organization, Geneva, Switzerland) for his valuable assistance in finalising some of the analyses for Tomsk Oblast, Russia.

For editorial comments see page 9 .

This article has supplementary material available from www.erj.ersjournals.com

Support Statement

The study was partly supported by grants provided to the World Health Organization by the United States Agency for International Development and the Bill and Melinda Gates Foundation.

Statement of Interest

A statement of interest for S. Keshavjee can be found at www.erj.ersjournals.com/site/misc/statements.xhtml

• Received September 30, 2011.
• Accepted December 7, 2011.
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Tomsk Oblast, Russia

The capital city of Tomsk oblast: Tomsk .

Tomsk Oblast - Overview

Tomsk Oblast is a federal subject of Russia located in the southeast of the West Siberian Plain, part of the Siberian Federal District. Tomsk is the capital city of the region.

The population of Tomsk Oblast is about 1,068,300 (2022), the area - 314,391 sq. km.

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History of Tomsk Oblast

The development of this region began in the late 16th - early 17th centuries. The oldest settlement in the Tomsk region is the village of Narym, founded in 1596.

The town of Tomsk was founded as a military fortress by the decree of Tsar Boris Godunov in 1604. It was one of the outposts of the development of Siberia.

From 1708 to 1782, Tomsk was part of the Siberian province. In 1804, the town became the center of a separate Tomsk province, which included the current territories of the Altai krai, Novosibirsk, Kemerovo, East Kazakhstan, Tomsk regions and part of Krasnoyarsk krai.

In the 19th century, the growth of gold mining, smelting of metals, fur trade concentrated large capital in Tomsk, triggering a revival of trade. Important transport routes - the Moscow and Irkutsk tracts - passed through Tomsk.

In 1888, the first university beyond the Urals was opened in Tomsk, in 1900 - the Technological Institute, in 1901 - the first commercial school in Siberia, in 1902 - the Teachers’ Institute. By 1914, Tomsk was one of the 20 largest cities in the Russian Empire.

In 1925, the Tomsk Governorate was abolished and became part of the Siberian region. In the 1930s, Tomsk lost its administrative significance. In August 1944, the city became again a regional center.

During the Second World War, dozens of factories, educational, scientific, and cultural institutions were evacuated to Tomsk oblast and became the basis for the further development of the region in the postwar years.

In the 1950s, the first in the USSR nuclear center of the world level was created in Tomsk Oblast - the Siberian Chemical Combine. In the 1960s-1970s, oil production began on the territory of the region, a giant petrochemical plant was built - the Tomsk Petrochemical Combine.

Nature of Tomsk Oblast

Small lake in Tomsk Oblast

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Beautiful nature of the Tomsk region

Author: Sergey Timofeev

Tomsk Oblast scenery

Author: Egor Dyukarev

Tomsk Oblast - Features

The length of the Tomsk region from north to south is about 600 km, from west to east - 780 km. Most of the territory is difficult to access because of taiga forests occupying about 60% of the region and marshes (28.9%). The Vasyugan swamp is one of the largest marshes in the world.

The climatic conditions of the southern and northern districts of the Tomsk region are markedly different. Almost the entire territory of the region is located within the taiga zone. The climate is temperate continental. The average temperature in July is plus 24 degrees Celsius, in January - minus 16 degrees Celsius. The climate in the northern part of the region is more severe, winters are longer.

The largest cities and towns of Tomsk Oblast are Tomsk (570,800), Seversk (105,200), Strezhevoy (38,900), Asino (24,400), Kolpashevo (22,200). Lake Mirnoye located in Parabelsky district is the largest lake. The main river, the Ob, crosses the region diagonally from the southeast to the northwest, dividing it into two almost equal parts.

The main industries are oil and gas, chemical and petrochemical, engineering, nuclear, electric power, timber industry, and food industry. All the machine-building and metal-working plants are located mainly in Tomsk and partly in Kolpashevo and Seversk. Oil is extracted mainly in the north-west and west of the region.

The main branches of agriculture are meat and dairy cattle breeding. Agricultural fields occupy about 5% of the territory. Wheat, flax and vegetables are grown in small amounts. Cattle-, pig-, sheep-, and goat-breeding are presented as well as poultry farming. Fur trade (squirrels, sables, musk-rats) and fur farming (silver-black fox) are also developed.

Tomsk Oblast - Natural Resources

Tomsk Oblast is rich in such natural resources as oil, natural gas, ferrous and non-ferrous metals, brown coal (the first place in Russia), peat (the second place in Russia), and groundwater. In the region there is the Bakcharskoe iron ore deposit, which is one of the largest in the world (about 57% of all iron ore in Russia).

Forests are one of the most significant assets of the region: about 20% (more than 26.7 million hectares) of forest resources in Western Siberia are located in Tomsk oblast. The timber reserves amount to 2.8 billion cubic meters.

In the Tomsk region there are 18.1 thousand rivers, streams and other watercourses with a total length of about 95 thousand km, including 1,620 rivers with a length of more than 10 km.

The main waterway is the Ob River. The Ob length in the region is 1,065 km. The main tributaries of the Ob flowing into it on the territory of the Tomsk region are the Tom, Chulym, Chaya, Ket, Parabel, Vasyugan, Tym.

Attractions of Tomsk Oblast

The sights of Tomsk Oblast include the harsh beauty of Siberian nature, the variety of winding rivers and canals, as well as monuments of wooden architecture, and other places that keep ancient legends about this land.

Undoubtedly, it is worth to visit Lake Kirek, one of the most beautiful reservoirs of the Tomsk region. It is located only 50 km from Tomsk. According to legend, a local millionaire drowned his diamonds here during the revolution in 1917.

About 40 km from Tomsk, there is a lake complex of the village of Samus consisting of seven lakes. These lakes are known for their very dark water, which is explained by the streams flowing into them from peat bogs.

Near the village of Kolarovo, located 33 km south of Tomsk, there is Siniy (Blue) cliff. It is a three-kilometer precipice descending to the Tom River. The cliff got its name due to the gray-blue shale that covers it. Several centuries ago, after the founding of Tomsk, a watchtower was installed on the cliff, from which signals were sent to the fortress.

At the source of the Berezovaya River, 40 km southeast of Tomsk, there is such an attraction as the Talovsky bowls, a natural monument of national importance. These are huge natural figures in the form of vessels of oval form, covered from the inside by birnessite - a rare mineral.

There is a tourist attraction of a global scale in the Tomsk region - the Vasyugan marshes, the largest marsh complex in the world. It is also called the “Russian Amazon”, because the Vasyugan marshes are not inferior to the famous South American river by their scale.

To the collection of sights of Alexandrovsky district of the Tomsk region, the most distant from the regional center, we can add Lake Baikal, the namesake of the famous lake, Goluboye (Blue) Lake, Malyye mountains (highlands) in the valley of the Vakh River and the Paninsky reserve, where the ancient burials of the Khanty and Ostyaks are preserved.

On the right bank of the Ob River, more than 200 km from Tomsk, the village of Mogochino is located. St. Nicholas Convent can be found here.

In Tomsk itself, plenty of monuments of wooden architecture deserve attention. In total, there are more than 700 objects, including 109 monuments of federal and regional significance.

Also in the Tomsk region you can visit more than 100 museums (most of them are located in Tomsk). The most popular museums are the Museum of History of Tomsk, the Memorial Museum “The NKVD Investigative Prison”, the Museum of Wooden Architecture, the Tomsk Regional Art Museum.

Tomsk oblast of Russia photos

Pictures of the tomsk region.

Abandoned village in Tomsk Oblast

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Orthodox chapel in the Tomsk region

Winter in Tomsk Oblast

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Field road in Tomsk Oblast

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Country life in Tomsk Oblast

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Kamala Harris celebrates the late Rep. Sheila Jackson Lee as a ‘force of nature' and a mentor

Services for jackson lee began on monday when hundreds of people paid their respects to her as her body lay in state in a flag-draped coffin inside houston’s city hall., by juan a. lozano and chris megerian | the associated press • published august 1, 2024 • updated on august 1, 2024 at 3:49 pm.

Vice President Kamala Harris on Thursday eulogized longtime U.S. Rep. Sheila Jackson Lee as a “force of nature” as memorials for the longtime Democratic lawmaker drew to a close.

Harris took time away from her presidential campaign to describe Jackson Lee, who represented Houston in Congress, as a coalition builder and expert in the legislative process. Harris joked about hiding in the hall when Jackson Lee walked by because the lawmaker was so intense.

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“She always expected in all of us that we would rise to a point of excellence, knowing that life was too short and there's too much to be done,” Harris said. She said she called Jackson Lee, who died July 19 at age 74 after being treated for pancreatic cancer, a few days before then to express her gratitude for their friendship.

"To honor her memory, let us continue to fight," Harris said.

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Harris is poised to be the first Black woman to be a major party's presidential candidate, and Jackson Lee was one of Congress' most prominent Black women during her nearly three decades in Washington. Jackson Lee helped lead federal efforts to protect women from domestic violence and recognize Juneteenth as a national holiday.

More than 50 members of the U.S. House attended Thursday’s funeral service. New York Rep. Hakeem Jeffries, the House Democratic leader, said Jackson Lee was a “voice for the voiceless.”

The crowd of several hundred in the church cheered and often stood during the service and at times people in the audience yelled out, “Thank you Sheila.”

Former President Bill Clinton said Jackson Lee was on his “just say yes” list whenever she called him during his time in office. She “really believed that we are all created equal,” he said, emphasizing, “We are the longest lasting democracy in human history because we had enough people like Sheila Jackson Lee.”

Services for Jackson Lee began on Monday when hundreds of people paid their respects to her as her body lay in state in a flag-draped coffin inside Houston’s City Hall. President Joe Biden placed a bouquet of flowers near her casket and visited with Jackson Lee’s family.

Arva Howard, 72, who was among the hundreds to pay respects Thursday, said Jackson Lee cared deeply for people. “We always knew if we needed something solved, Sheila was the person to go to,” Howard said.

Before the service, Calandrian Simpson Kemp, 53, posed next to a large photo of Jackson Lee in the church’s foyer while holding up a photo of her 20-year-old son, George Kemp Jr., who died from gun violence in 2013. Simpson Kemp said Jackson Lee was a mentor in Simpson Kemp’s efforts to stop gun violence and enact common sense gun laws after her son’s death.

“When I think of Sheila and her legacy, I think about empowerment. I think about the power of one,” Simpson Kemp said. “She never let up for people. She left it all on the battlefield, and I think it’s up to us now to pick up the torch.”

Jackson Lee represented her Houston-based district since 1995. She previously had breast cancer and announced the pancreatic cancer diagnosis on June 2.

Before being elected to Congress, Jackson Lee served on Houston’s city council from 1990 to 1994.

In Washington, Jackson Lee established herself as a fierce advocate for women and minorities and a leader for House Democrats on many social justice issues, from policing reform to reparations for descendants of enslaved people. She led the first rewrite of the Violence Against Women Act in nearly a decade, which included protections for Native American, transgender and immigrant women.

Jackson Lee unsuccessfully ran to be Houston’s mayor last year.

SHEILA JACKSON LEE

‘She was unrelenting in her leadership,' President Biden remembers US Rep. Sheila Jackson Lee in Houston

US Rep. Sheila Jackson Lee of Texas to lie in state at Houston city hall

Biden praises longtime US Rep Sheila Jackson Lee of Texas, who died of cancer

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